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One day, whilst reviewing our daily ED results basket
we decided we had had enough...
Why were we doing so many tests!! Was this evidence based?
Was it out of habit?
Were clinicians scared of missing things?
Were clinicians scared of looking foolish?
Why were so many tests coming back normal?
Were we doing the right tests on the right people?
Was there anything we could do?
No Unnecessary Tests – Why we are going NUTs about ED medical testing
So, we decided to look into it.
Our aim?
Firstly, we engaged with a cross section of ED clinicians in formal redesign
sessions.
Then we collected 3 years worth of background pathology and imaging data.
And finally we started implementing a multipronged change process:
Formal research projects using evidence based clinical guidelines
“Optimising the quality and numbers of urine samples sent to Microbiology from the Emergency Department”
“Implementation of an evidence based pathway to enhance rational imaging in suspected pulmonary embolism”
Electronic decision support Senior clinician sign off within our EDIS for CRP, Clotting, VBG, CMP
Weekly education packages highlighting some key topics
Engagement of senior clinical staff as change champions
And we have seen some results!
Combined strategies were implemented in November 2015
Path tests per ED presentation CRP ordering per ED presentation CTPA/VQ weekly ordering
But most importantly of all we have seen a Culture change: Bedside clinical conversations, increased patient engagement, positive comments by new staff.
Did we learn anything?
Yes! Clinicians love guidance in this area.
“Ordering gases is no longer a reflex action”
“It helps me to think about what I order”
“The PE pathway gives me a structure to my ordering”
BUT sustainability requires ongoing vigilance
What next?
Ongoing education to ensure sustainability
New ED projects and expansion to other Eastern Health campuses.
Expansion into the inpatient setting
Different challenges - larger and more diverse group of clinicians
- focus on frequency rather than breadth of testing
Conflicts of interest EH PE study - EasternHealth Foundations Research Grant kindly provided by House Husbands
All other work to date has been internally funded by Eastern Health
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Authors Dr Paul Buntine, A/Prof Deb Leach, Emergency Department, Box Hill Hospital, Eastern Health, Melbourne,.
Monash University Medicine, Nursing and Health Sciences
Acknowledgments: Jo-Anne McShane, Research Nurse Contact: [email protected]
Monthly ED Urine M/C/S requests
To reduce unnecessary testing in our Emergency Department
as defined by our clinical “NUTs” working group
